Based upon observations, interviews, and record review, the facility failed to implement care plan interventions for safe transfer with a mechanical lift for 1 out of 24 residents reviewed. (Resident #27)The findings include:On 8/13/25 at 08:25 AM, an observation of Resident #27 was conducted. Resident #27 was observed in a mechanical lift sling, suspended midair over the bed. Staff Member B (a Certified Nursing Assistant (CNA)) present in the room, retrieving Resident #27's wheelchair, removing the leg rest that was sitting on wheelchair seat. Staff Member B was interviewed at this time and stated, I'm getting her up now. When asked about the protocol for transferring Resident #27, Staff B stated, we always use two person assist when using a mechanical lift, but the other CNA and nurse were busy down the hall, so I did it myself. An interview was conducted with the Administrator and Director of Nursing on 8/13/25 at 09:00 AM. They acknowledged that transfers with a mechanical lift require a two person assist at all times. Resident #27's plan of care revealed a self-care performance deficit due to dementia, confusion, activity intolerance, and impaired balance, with a goal to continue to participate with self care throughout the review period. Interventions include transfer using a full body mechanical lift for all transfers with 2 staff person assist.The facility policy for safe resident handling and transfers states, .it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe secure and comfortable experience for the resident while keeping employees safe in accordance with current standards and guidelines. The facility-wide education on use of mechanical lifts dated 2/28/25 (which included a signature by Staff Member B) states, Two staff members must be utilized when transferring residents with a mechanical lift. (photographic evidence obtained)

Based on observations, interviews and records review, the facility failed to review and revised the care plan to address the needs of 1 of 1 residents reviewed. (Resident #120)The findings include: On 08/12/25 at approximately 10:35 AM, Resident #120 was observed resting in her room with an external heart monitor taped to her upper chest, displaying a red blinking light.On 08/12/25 at approximately 3:00 PM, an interview was conducted with Resident #120. She reported that on 08/11/25, she attended a follow up appointment with her cardiologist, during which an external heart monitor was placed to evaluate her for possible atrial fibrillation. Upon returning to the facility, she provided the related paperwork to a staff member.On 08/13/25 at approximately 8:30 AM, the receptionist confirmed that Resident #120 had a follow-up appointment outside the facility on 08/11/25.On 08/13/25 at approximately 12:33 PM, an interview was conducted with Staff A, Registered Nurse. She explained that, when a resident returns to the facility from a physician's appointment with new orders, the nurse on duty will verify the orders and document a progress note in the resident's record.On 08/13/25 at approximately 12:40 PM, an interview was conducted with the Director of Nursing. She acknowledged that the resident had a physician's appointment on 08/11/25. She stated that she did not become aware until today that the resident had a heart monitor, and this is the first time the staff has knowledge of it. She explained that it is the facility's expectation to have the resident assessed and a progress note entered into the resident's record upon return. She further confirmed that, for approximately 48 hours, the facility was not aware of the heart monitor and therefore did not implement monitoring of the device or update the care plan.A shower and skin monitoring sheet, dated 08/12/25 for Resident #120, was reviewed. There is no acknowledgment of the heart monitor (Photographic evidence obtained).Progress notes for Resident #120 from 08/11/25 and 08/12/25 were reviewed. There are no entry notes from the nursing staff regarding the new heart monitor.On 08/13/25 the care plan for Resident #120 was reviewed. The care plan was not updated to reflect the heart monitor device (Photographic evidence obtained).

Based on record review and interview, the facility failed to submit the Payroll-Based Journal (PBJ) report correctly for 1 of 4 quarters reviewed. The findings include: A review of the PBJ data report submitted into the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of 2024, which reports on the period of October 1 to December 31, 2023, revealed excessively low weekend staffing. On 5/19/24 at 12:39 pm, the facility's Administrator was interviewed. He stated the facility had not been low staffed on weekends. He stated that the corporate office did not fill the form correctly.

Based on record review, review of immunization records, and facility policy the facility failed to provide education and offer COVID 19 vaccines in a timely manner for 4 of 5 sampled residents. (Residents #15, #28, #39, #64) The findings included: On 5/20/24, a review of the immunization record of Resident #15 was conducted. The record had an influenza vaccine dated 10/5/2023. There was no COVID vaccine in the record at the time. On 5/21/24, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and or declination forms. On 5/22/24, the Director of Nursing (DON) provided proof of COVID vaccines given on 1/4/21, 2/4/21, 3/8/21, and 6/22/22. The facility did not provide proof of approval or refusal of COVID vaccines after 6/22/22. On 5/20/24, a review of the immunization record of Resident #28 was conducted. The record had documentation of the administration of the COVID vaccine dated 1/14/21, 2/14/21, 11/5/21, and 8/1/22. On 5/21/24, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and/or declination forms. The facility did not provide proof of any of these forms after 8/1/22. On 5/20/24, a review of the immunization record of Resident #39 was conducted. The record had documentation of the COVID vaccine on 1/14/21, 2/4/21, and 11/14/21. The facility did not provide proof of approval or refusal of the COVID vaccine after 11/14/2021. On 5/20/24, a review of the immunization record of Resident #64 was conducted. The record had documentation of an influenza vaccine dated 10/5/2023. There was no proof of offering the COVID vaccine in the record at the time. On 5/21/23, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and or declination forms. On 5/22/24, the Director of Nursing provided proof of a COVID vaccine given on 11/1/21. The facility did not provide proof of any acceptance or refusal of a COVID vaccine after 11/12/21. On 5/22/24 at approximately 1:00 PM, the DON provided COVID 2023 Booser Immunization Consent Forms dated 5/22/24 for Residents #15, #28, #39, #64. Resident #15's family had been contacted verbally and the resident and his family refused the vaccine. Resident #28's guardian had been contacted verbally. The guardian wished for the resident to continue the Pfizer booster but refused the Moderna vaccine. Resident #39's guardian had been contacted verbally. The guardian wished for the resident to continue the Pfizer booster. Resident #64's guardian had been contacted verbally. The guardian wished for the resident to continue the Pfizer booster but refuses the Moderna vaccine. On 5/22/24 at approximately 2:30 PM an interview was conducted with the DON. She was asked when the COVID 2023 Boosters Immunization Consent forms for the residents were completed. The DON acknowledged that they contacted the residents and their families earlier in the day. She mentioned that several residents preferred to receive the covid vaccine from Pfizer. She explained that the facility had a binder for tracking the immunizations. The binder had been lost the past November when all of the medical records were being uploaded into the electronic record. The DON was asked who was responsible for tracking, ordering, providing vaccinations at the facility. She explained that there are three Assistant Directors of Nursing (ADON) and each ADON is responsible for tracking, ordering providing and following up on immunizations for residents in their area. The Facility Administrator indicated that a performance improvement plan (PIP) was initiated that am to track and update immunizations. A copy of the PIP was provided indicating that the facility had started an audit of all in house residents covid vaccines and consent forms had been initiated on 5/22/24. On 5/22/24 a review of the infection prevention and control policy, dated July 2023, was conducted. Page 2 of the policy indicated that residents would be offered the vaccine. Residents and resident representatives will have the opportunity to accept of refuse a COVID-19 vaccine and changed their decision based on current guidance.